A child’s first years of life are crucial for cognitive development and future health. Studies show that a varied diet with a high intake of vegetables is positive for both weight and cognitive development. The present low intake of vegetables in children’s diets is therefore a concern.
Trang 1S T U D Y P R O T O C O L Open Access
A cluster randomized web-based
intervention trial to reduce food neophobia
and promote healthy diets among
one-year-old children in kindergarten: study
protocol
Eli Anne Myrvoll Blomkvist* , Sissel Heidi Helland, Elisabet Rudjord Hillesund and Nina Cecilie Øverby
Abstract
Background: A child’s first years of life are crucial for cognitive development and future health Studies show that a varied diet with a high intake of vegetables is positive for both weight and cognitive development The present low intake of vegetables in children’s diets is therefore a concern Food neophobia can be a barrier for vegetable intake in children Our hypothesis is that interventions that can increase children’s intake of vegetables should be introduced early in life to overcome children’s neophobia This study aims to develop, measure and compare the effect of two different interventions among one-year-old children in kindergartens to reduce food neophobia and promote healthy diets
Methods: The kindergartens are randomized to one of three groups: two different intervention groups and one control group We aimed to include a total of 210 children in the study The first intervention group will be served
a warm lunch meal with a variety of vegetables, 3 days a week during the intervention period of 3 months The second intervention group will be served the same meals and, in addition, kindergarten staff will be asked to implement pedagogical tools including sensory lessons, adapted from the Sapere method, and advices on meal practice and feeding practices The control group continues their usual meal practices Parents and kindergarten staff will complete questionnaires regarding food neophobia, food habits and cognitive development at baseline and post intervention A similar intervention among 2-year-old children in kindergarten has been implemented and evaluated earlier We will investigate whether a digital version of this intervention has an effect, because digital interventions can be easily implemented nationwide We will also investigate whether there are benefits of
conducting such interventions in younger children, before the onset of food neophobia Questionnaires,
information videos and recipes will be digitally distributed
Discussion: Results of this study will provide new knowledge about whether a sensory education and a healthy meal intervention targeting children, kindergarten staff and parents will reduce levels of food neophobia in
children, improve parental and kindergarten feeding practices, improve children’s dietary variety, improve children’s cognitive development and reduce childhood overweight
Trial registration:ISRCTN98064772
Keywords: Children, Kindergarten, Food neophobia, Diet variety, Parental feeding practices, Cognitive development, Overweight, Sapere method, Sensory education
* Correspondence: eli.anne.myrvoll.blomkvist@uia.no
Faculty of Health and Sport Sciences, Department of Public Health, Sport and
Nutrition, University of Agder, Kristiansand, Norway
© The Author(s) 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver
Trang 2What we eat has significant impact on health and disease
[1] In Norway, eating an unhealthy diet is the second
most important risk factor for disease burden [2] A low
intake of fruits and vegetables and a high intake of energy
dense foods increases the risk for non-communicable
dis-eases [1, 3, 4] To reduce this risk The World Health
Organization (WHO) recommends an increased intake of
fruit and vegetables throughout the world [5] The
in-creasing prevalence of obesity among children is a global
health challenge [6, 7] Although an inverse relationship
between fruit and vegetable intake and obesity in children
remains somewhat unclear [8], a healthy dietary pattern
with a high intake of fruit and vegetables is crucial for
health and development Studies have also shown that diet
has an impact on children’s cognitive development [9],
and that healthy dietary patterns in childhood can
influ-ence cognitive and neuropsychological outcomes [10,11]
The World Health Organization (WHO) has stated that
proper nutrition during the 1000 days between a woman’s
pregnancy and her child’s 2nd birthday (the 1000 day
win-dow) has a profound impact on a child’s ability to grow,
learn and thrive, and hence a lasting effect on a country’s
health and prosperity [12]
In Norway the average intake of fruits and vegetables
in one-year old children is only half of the
recom-mended intake [13] A low intake of vegetables is
par-ticularly challenging regarding health A national survey
found that one-year old children ate only 32 g of
vegeta-bles per day on average [13] One barrier for vegetable
intake in children is food neophobia, meaning a
reluc-tance to taste and eat new foods This trait is most
expli-cit in children between 2 and 6 years of age [14] Food
neophobia is associated with a low intake of vegetables
and a poorer dietary quality [15, 16] Helland et al [17]
found that food neophobia was negatively associated
with intake of fruit and vegetables, berries and fish in
two-year olds Moding and Stifter [18] suggest that
re-jection of new foods during infancy predicts neophobia
during early childhood Fletcher et al [19] found that an
early liking for fruit and vegetables predicted increased
later intake, so they hypothesize that increasing early
ex-posure to fruit and vegetables may have long-term
bene-ficial consequences
Food neophobia and scepticism to eat new foods is
modifiable Several intervention studies have shown that
repeated exposure, where pre-school children are
ex-posed to either vegetables alone or to vegetables
com-bined with other flavours, for instance a dip or sauce,
can increase children’s willingness to taste and eat
vege-tables [20–24] Researchers have also found that hiding
vegetables in mixed courses can be an effective strategy
to increase children’s vegetable intake [25] Role
model-ing is a well-known strategy that can influence food
intake in children [26–29] Social Cognitive Theory sug-gests that modelling by teachers or by peers, would be one of the most effective methods to encourage food ac-ceptance in preschool children [30] Hendy et al [26] found that enthusiastic teacher modelling was more ef-fective than silent teacher modelling, and that peer mod-elling was the most effective method to encourage new food acceptance in preschool children
Another area of research is sensory education, allow-ing children to explore foods with their senses by smell-ing, touchsmell-ing, hearsmell-ing, watching and tasting The aim of sensory training is to increase the willingness to taste new foods and thereby increase intake of vegetables or other foods in children [31–34] The Sapere method based on Puisais’ work Le Gỏt de L’enfant [35] can be one way of learning about food through senses and lan-guage in kindergartens and schools The sensory-based food education programme, which originated in France, has since been translated to Swedish [36] and is being used both in schools and kindergartens in Sweden [37]
To our knowledge, the Sapere method has not been sub-ject to research in preschoolers in Norway except from the study done by our research group [38] Helland et al [17,38] have tested the Sapere sensory education in tod-dlers between the ages of two and 3 years We will now investigate whether there are benefits of conducting such interventions in younger children, before the usual onset
of food neophobia
Toddlers in Norway spend much of their time in kin-dergarten and more than 80% of all children between 1 and 2 years of age attend kindergarten [39] The recent (2017) Framework plan for kindergartens [40] suggests that kindergarten staff use mealtimes and cooking to en-able the children to enjoy food, participate, communi-cate and feel togetherness Food and feeding practices in kindergarten can influence children’s diet and eating habits [41], and kindergarten staff have a great responsi-bility and opportunity when it comes to teaching chil-dren about food and meals The kindergarten setting is
an arena where both repeated exposure to new foods and sensory education can be implemented systematic-ally, as well as an arena where the importance of care-givers as role models can be explored
The Internet plays an important role in our everyday lives A recent review found that caregivers use the inter-net for both information, support and education [42] An earlier study in seven European countries found that 71%
of Internet users had used the Internet for health purposes [43] It is reasonable to believe that the proportion is even higher today A recent study showed that providing kindergarten and elementary school educators with web-based resource materials improved their attitudes, in-creased their knowledge and lead to positive behavioural intentions concerning educating their students about oral
Trang 3health [44] We believe that this can be applied to other
health concerns as well
The aim of the present study is to develop and evaluate
the effect of two different interventions among one-year-old
children in kindergartens in four counties in Norway The
interventions aims to promote a healthy and varied diet in
young children that can facilitate cognitive development and
help to prevent future overweight
Outcomes
Primary outcomes:
1 Child vegetable intake assessed at baseline, after the
intervention, and at the ages of 36 and 48 months
2 Children’s level of food neophobia assessed at
baseline, after the intervention, and at the ages of
36 and 48 months
3 Child dietary habits and food variety assessed at
baseline, after the intervention, and at the ages of
36 and 48 months
Secondary outcomes:
4 Child cognitive development assessed at baseline,
after the intervention, and at the ages of 36 and
48 months
5 Self-reported weight and height assessed at baseline,
and at the ages of 36 and 48 months
6 Parental and kindergarten staff feeding practices
assessed at baseline, after the intervention, and at
the ages of 36 and 48 months
Methods
Study design
This study is a cluster randomized controlled trial It is
an ongoing study
The kindergartens are randomized to one of three
groups: two different intervention groups and one control
group We aimed to include 210 children in the study
A similar intervention among 2-year-old children in
kindergarten has been implemented and evaluated
earl-ier [38] and we will now investigate the effect of a digital
version of such an intervention, because a digital
inter-vention can be more easily implemented into
kindergar-ten daily life Information videos and recipes for the
project will be included in a password protected study
web page and questionnaires will be distributed by
The protocol for the present study was approved by
the Norwegian Centre for Research Data (ref.nr 49951)
Informed consent was obtained from the kindergarten
manager and from one of the parents of all participating
children when registering for the study
Recruitment and participants
The kindergartens were recruited from four counties in Norway; Telemark, Oppland, Sør-Trøndelag and Møre
og Romsdal An invitation to participate was first sent by e-mail to the managers of kindergartens in the two counties Telemark and Oppland and due to low partici-pation, two new counties were included: Sør-Trøndelag and Møre og Romsdal The invitations were sent to kin-dergartens registered at The Norwegian Directorate for Education and Training (UDIR) (n = 1080) Kindergar-tens registered as “open” kindergartens where children and their parents attend together (n = 18), kindergartens registered with less than 4 children (n = 7) and kinder-gartens with children from 3 to 5 years only (n = 12) were not invited to participate (Fig.1) The invitation in-cluded detailed information about the study and a link
to the study registration web page A reminder e-mail was sent to the kindergartens 2 weeks after the first e-mail Because few kindergartens (n = 32) registered for the study initially, a random selection of kindergartens
in all four counties was additionally contacted by phone (n = 321) A total of 48 kindergartens registered for the study (Fig.1) Two of the kindergartens withdrew before randomization because they had fewer than three chil-dren born in 2016 (Fig.1)
The pedagogical leaders in the participating kindergar-ten departments were asked to distribute an electronic invitation letter to the parents providing information about the study and a link to the registration web page where parents could register their child to participate in the study Inclusion criteria for the children participating
in the study was that they had to be born in the year of
2016 and that at least one of the parents could read and understand Norwegian A total of 267 children were reg-istered for the study (Fig.1)
Intervention
The participating kindergartens (n = 46) were random-ized into two different intervention groups and one control group Children in the first intervention group will be served a warm lunch meal with a variety of vegetables, 3 days a week during the intervention period that will last for 3 months After 3 weeks with the first menu there will be a one-week break before starting the serving of meals from the second menu 3 days a week in three more weeks and after another one-week break, 3 weeks with the third and last menu The kindergartens will have access to a total of nine different recipes in a password protected web page especially designed for each intervention group (Table 1) Each of the three menues has one “focus” vegetable, i.e spinach, celeriac and fennel A mini-mum of two meals per week will include the focus vegetable so that the children are exposed to each
Trang 4vegetable at least six times during the menu period of
3 weeks (Table 1)
Children in the second intervention group will be served the same meals from the same menus as described for intervention group 1 In addition the kindergarten staff in intervention group 2 will be asked to implement peda-gogical tools including i) weekly sensory lessons (Sapere method) [35] for the participating children and ii) advice
on meal practice and feeding practices during mealtime Children participating in the sensory lessons will have three more exposures, a total of at least nine exposures, of the selected“focus” vegetables
Meal practice and Feeding practices recommendations are presented in short information videos on the study web page which is only available for the second inter-vention group The videos contain information about food neophobia, repeated exposure, role modeling, our five senses, basic tastes, and the Sapere method
The control group will continue their usual meal practices
Measurement instruments
To evaluate the effect of the interventions on the given outcomes, parents and kindergarten staff will complete questionnaires at baseline and post intervention There will be follow-up-questionnaires when the children are
36 and 48 months old
A main questionnaire to the parents including all the outcome variables has been developed specifically for this study, except measures of cognitive development which is measured with the Ages and Stages Questionnaire (ASQ) [45] A separate questionnaire was developed for the peda-gogical leaders in the participating departments All mea-surements are described in detail below
Measures of child food neophobia
Child food neophobia is measured with a 6-item version
of Pliner’s 10-item Child Food Neophobia Scale (CFNS) [46] The Child Food Neophobia scale (CFNS) is a vali-dated tool which uses parental reporting of child neo-phobia The 6-item version of CFNS is commonly used
to measure food neophobia in young children and has been used with children as young as 2 years [15, 17,47,
48] Responses are ranged from “strongly disagree” to Fig 1 Flowchart of the study design
Table 1 Lunch dishes cooked in the intervention kindergartens
Menu 1 spinach
Pasta with vegetables and feta cheese (includes spinach)
Pan fried fish with carrot purée
Spinach and lentils soup
Menu 2 celeriac
celeriac purée
Vegetable stew (includes celeriac) Menu 3
fennel
Minestrone soup (includes fennel)
Fish cakes with oven baked vegetables (includes fennel)
Potato and broccoli omelet
Trang 5“strongly agree” on a seven-point scale The CFNS items
have been translated from English into Norwegian, and
back-translated into English by members of our research
group earlier [17] The CFNS was included in the
paren-tal questionnaire
Measures of parental and kindergarten staff feeding
practices
Parental and kindergarten staff feeding practices is measured
with the Comprehensive Feeding Practices Questionnaire
(CFPQ), which has been validated earlier [49] CFPQ has
been used to assess parental feeding practices at 18 months
[50], and has already been translated to Norwegian and
vali-dated in parents of 10-to-12-year-olds [51]
The original CFPQ includes 12 subscales The following
eight subscales are included in the parental questionnaire
when the child is 1 year old: Child control, Emotion
regula-tion, Encourage balance and variety, Environment, Food as
reward, Modeling, Pressure and Restriction for health The
four other subscales: Involvement, Monitoring, Restriction
for weight control and Teaching about nutrition will be
in-cluded in the parental questionnaire to be used when the
children have reached the age of three and 4 years
Kindergarten staff will complete a modified version of
the CFPQ, adapted to a kindergarten context The
fol-lowing seven subscales were included in the
question-naire to the pedagogical leaders: Child control, Emotion
regulation, Encourage balance and variety, Food as
re-ward, Modeling, Pressure and Restriction for health
Measures of children’s food intake, food variety and
vegetable liking
Child food intake and food variety is measured by
se-lected items from a food frequency questionnaire that
has been validated and used in large national surveys
[13] Amounts of food is not measured, only frequencies
of intake Questions on how often the child eats fruits,
berries, vegetables and potatoes are included, in addition
to questions about bread and cereals, drinks, warm
meals and snacks The response options for intake of
fruits and vegetables are: never, < 1/month, 1–3/month,
1–2/week, 3–4/week, 5–6/week, 1/day, 2/day, > 3/day
In addition to these food frequency questions, questions
about duration of breastfeeding and time of introduction
to solids are also included
Measure of vegetable liking is adapted from a
ques-tionnaire used in the Australian study Nourish [52] The
answers are graded as 1: likes a lot, 2: likes a little, 3:
nei-ther likes or dislikes, 4: dislikes a little, 5: dislikes a lot,
6: never tried
Measures of food refusal and food fussiness
Questions about child food refusal and food fussiness
were adapted from The Nourish study questionnaires
for children at the age of 14 months and 2 years [52] Questions were translated into Norwegian by the author and back-translated by two co-authors to ensure that the meaning of the questions remained the same as in the original questionnaire
Measures of weight and height
Measures of weight and height are self-reported Parents are asked to report child weight and height in the most recently health control from the children’s health card
Measures of other variables
Food frequency questions about parental intake of fruits, berries and vegetables, as well as questions about paren-tal age, height and weight, ethnicity, length of education and occupation are also included in the questionnaire Level of food neophobia in parents and kindergarten staff is measured with the original 10-item version of the FNS [53]
Questions about the kindergartens meal routines and food serving are included in the questionnaire to the pedagogical leaders
Measures of cognitive development
Children’s cognitive development is measured with the Ages and Stages Questionnaire [45] This questionnaire has been widely used in both clinical and research set-tings in several countries [54,55] It consists of 19 differ-ent questionnaires covering the age-range of 4 to
60 months The questionnaires cover five different do-mains: communication, gross motor, fine motor, prob-lem solving and personal social skills The Norwegian version of ASQ has also been validated [56]
Compliance with intervention elements
The pedagogical leaders in the two intervention groups will complete a weekly short evaluation form on the study web page They are asked to assess the success of the implementation of the intervention elements on a scale of zero to ten and to describe whether there are discrepancies from the project plan as described in the study web page
Sample size calculation
Sample size was calculated according to the primary out-come food neophobia A previous cross-sectional trial of
505 toddlers in Southern Norway [17] resulted in a mean neophobian score of 18.2 (SD:9.3) We assumed that a mean score reduction in the level of food neopho-bia from 18.2 to 12.0 would be of public health value Using a power of 80% and type 1 error of 5%, this sug-gested 36 participants were needed in each group To adjust for within cluster variation we assume an intra-cluster correlation coefficient of 0,1 and a design
Trang 6effect factor of 1,6 expecting 7 participants in each
clus-ter [57] Based on these calculations we would need 58
participants in each group Due to a probable loss of
participants of 20%, we aimed to recruit 70 children in
each of the three groups, a total of 210 children in this
study
Randomization
The 46 registered kindergartens were randomized from
a block of 48 into three groups
Data analysis
Data will be analyzed when the data collection is
com-pleted during springtime 2018
Our primary goals are to detect differences in food
neophobia scores, vegetable intake and food variety
be-tween each of the intervention groups and the control
group
Discussion
Children today spend a large amount of time in Kindergarten
Kindergartens are a potentially important setting for
influencing children’s food choice at an early age and
there has been a call for intervention studies in this
field [58] With this study we are investigating the
ef-fectiveness of a web-based multi-component
interven-tion in kindergarten We have developed a web-based
intervention that may easily be implemented in
kin-dergartens throughout the country The intervention
kit includes three elements: a pedagogical tool (the
Sapere method), a menu of associated lunch dishes
and information videos targeting kindergarten staff
and parents
The strengths of our study are that it is being
con-ducted in a natural setting, making it possible to
repro-duce in other kindergartens if it shows an effect The
Sapere method is widely used in some countries;
how-ever, few studies have evaluated its effect on children’s
diet and health [35] Further, distributing all study
infor-mation electronically increases the availability of the
inter-vention, making it easy for kindergarten staff and parents
to find and use the recipes and tools It may also be easier
to track the children’s parents for follow-up-studies since
the questionnaires are distributed by e-mail To our
know-ledge there are few, if any, intervention studies on child
food neophobia that has targeted children before the onset
of neophobia, normally around the age of 2 years In
addition to investigating methods to reduce child food
neophobia and increase child dietary variety, we also
in-vestigate if a dietary intervention in kindergarten can
im-prove children’s cognitive development
However, our study also has limitations Recruitment
of kindergartens and parents turned out to be quite
diffi-cult It was also quite challenging to distribute the ASQ
because there are different questionnaires for different ages (in months), and the registered children varied in age between 10 months and 20 months The results of the study are based on parent-reporting which may have its weaknesses
Conclusion Results of this study will provide new knowledge about whether a sensory education and a healthy meal inter-vention targeting children, kindergarten staff and parents will reduce levels of food neophobia in young children, improve parental and kindergarten feeding practices, im-prove children’s dietary variety, imim-prove children’s cog-nitive development and reduce childhood overweight This study will also provide knowledge about whether
an electronically distributed intervention could be easily implemented in kindergartens nationwide
Abbreviations
ASQ: Ages and stages questionnaire; CFNS: Child food neophobia scale; CFPQ: Comprehensive feeding practices questionnaire; FNS: Food neophobia scale
Acknowledgements The authors would like to thank the Norwegian Women ’s Public Health Association, University of Agder, the Teacher ’s Education Unit at the University of Agder and the Hospital of Southern Norway for their financial support.
The authors would also like to thank the Division of Communication at University of Agder for their help with web-design, pictures and information videos for the project.
Authors ’ contribution NCØ and EAMB developed the study EAMB, NCØ, ERH and SHH contributed
to the development of questionnaires and design, and EAMB conducted data collection NCØ and EAMB drafted the manuscript with critical input from all authors All authors have read and approved the final manuscript Funding
This research project is funded by the Norwegian Women ’s Public Health Association, and some projects costs were funded by the University of Agder and the Teacher ’s Education Unit at the University of Agder Approximately 1/5 of the wages cost for the corresponding author is funded by the Hospital of Southern Norway.
Availability of data and materials
We do not wish to share our data before we have thoroughly analyzed it Ethics approval and consent to participate
The protocol for the present study was notified to the Norwegian Social Science Data Services, Data Protection Official for Research, 13/09/2016, reference 49951 Informed consent was obtained from parents of all participating children and from all participating kindergartens and kindergarten staff.
Consent for publication Not applicable.
Competing interests The authors declare that they have no competing interests.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Trang 7Received: 28 March 2018 Accepted: 2 July 2018
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